HomeMy Public PortalAbout9154 WOOLLEY ST_Sewer__ 246,50 INSERTS
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7AeazO APPLICATION FOR PERMIT
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COUNTY oSEWER-SEWAGE DISPOSAL l
ra LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �
ADDRESS
JOHN A. LAMBIE, County Engineer _
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
'FOR APPLICANT TO FILL. . CRDs ST.
.I
LEGAL �7 ` cq a-` y
DESCRIPTION LOT NO. �� OWNER� J (� I�� ' L y" 'L.}��"
MAIL
BLOCK TRACT ADDRESS z.-& jj, �/y'Z fit"
O.OF BLDGS. �_ -
SIZE OF LOT NOW ON LOT CITY TEL, N0. S r
USE OF
BUILDINGS _ .DiSTI21CT N0. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR p* 9 y J✓ '"
ADDRESS I� _P e, �; - CONNECTION'DATA
CITY ' i t % TEL.NO.-= f s f., STATION ;' `'- DEPTH
/ 'r qy; STATE MANHOLE R'EFERCNCE
REGISTRATION N0. .J a COUNTY LOW'Egg.
NO. I DESCRIPTION OF WORK FEE
HOUSE SEWN R CONNECTING TO +
PitB_LIC SEWER C4rbo
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P.L; M.L.TO P.L.
_ PITSAND/OR DRAI_NF!ELD_ @ $8.00
OVERFLOW SEEPAGE PIT. DRAINFIELD
EX'TN..CESSPOOL.DRYWELL @ $2.00
HOUSE"SEWER CONNECTING TO P.C,NO.
RilATE DISPDSAI,,SYS;EM @ S1.00 CO.IMP. NO. JOB N0,
,COY VECT ADDITiONAL BLDG.OR ? 'TRUNK PERMIT ONO. ROAD PERMIT NO. OV
W 0 R K TO HSE SE WE:R C.%-ri8`JO _
SEW,ALTCxc 'S $1.00 SYSTRA EM HOUSE $1.00 T STATE ENCROACHMENT --- - -
i _PERM(, NO, _ - - 00
NDUSTRIAL U
L WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 , 00 CON14ECTION CHARGE FEE
AUTHOPUATION TOTAL FEE I IJ ' REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. _ -SIGNED THIS'THIS ,' 7 DAY OF=,/ 191,2, _NEW HOUSE SEWER i
OWNER. OR - CONNECT ADDITIONAL
_BU[LDING OR WORK
ADDRE55�� - SEPTIC TANK,SEEP.PIT(S)
-- AND/OR DRAINFIELD
�I HEREBY' ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRY'WELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMCING AND SEWERS. _ SEWAGE DISPOSAL,SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG ANDCE
LIC AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON }{0'JSE SEWER
CALIFORNIA OR THAT 1 PM THE LEGAL OW R F THE ABOVE
DESCRIBED RESIDENTIAL PROP ER!Y, BACKFILL SEPTIC TANKS ❑
SIGNATURE ,ya ;-� .P ,,q- _SEEP.PIT(S) ❑ CE.SSP00LS
OF PERMITTEE f J
P --VALIDATION ROBERT A. WOOD
CK./ M,0, CASH SUPERVISING MECHANICAL ENGINEER